Background Information

Definition

PID: ascending infection of the upper genital tract from the endocervix

PID is a general term that covers one or more of the following:

• Endometritis — inflammation and infection of the uterus
• Salpingitis — inflammation of the fallopian tubes
• Parametritis — inflammation of the parametrium, the connective tissue of the pelvic floor
• Oophoritis — inflammation of the content of one or both ovaries
• Tubo-ovarian abscess — due to complex infection of the adnexae
• Pelvic peritonitis — inflammation of the peritoneum.

Causes

Most commonly caused by STIs:

• Chalmydia trachomatis – most common (14-35%)
• Neisseria gonorrhoea
• Mycoplasma genitalium

Risk Factors

Risk factors related to sexual behaviour:

• <25 y/o
• Not using condoms
• <15 y/o at onset of sexual activity
• Multiple sexual partners
• Recent new sexual partner (<3 months)
• Previous PID
• History of STI in the women / sexual partner

Recent uterus instrumentation from:

• Termination of pregnancy
• Insertion of IUD (only increases risk for 3 weeks)
• hysteroscopy / hysterosalpingography
• IVF

Clinical Features

Symptoms:

• Lower abdominal pain (typically bilateral)
• Deep dyspareunia
• Abnormal vaginal bleeding
• Secondary dysmenorrhoea

Signs:

• Adnexal tenderness
• Vaginal / cervical discharge (often purulent)
• Cervical motion tenderness
• Systemic upset (fever, nausea, vomiting, malaise)

Complications

• ↑ Risk of ectopic pregnancy 
• Infertility
• Chronic pelvic pain
• Tubo-ovarian abscess
• Perihepatitis (Fitz-Hugh-Curtis syndrome)

Guidelines

Investigation and Diagnosis

PID is a clinical diagnosis. Antibiotics should not be delayed while awaiting laboratory test results.

• BASHH recommends considering a diagnosis of PID and offering treatmnet in any <25 y/o women with recent onset, bilateral lower abdominal pain +  local tenderness on bimanual examination.

Consider the following tests (not needed for diagnosis):

Test	Notes
Pregnancy test	To exclude ectopic pregnancy
Blood tests	↑ Leukocyte / CRP / ESR may support diagnosis
Vaginal swabs for chalmydia + gonorrhoea + Mycoplasma genitalium	-ve Swab does not rule out PID
STI screen	Including HIV, hepatitis serology, and syphilis serology
Wet mount vaginal smear under microscope	Good -ve predictive value (absence of pus cells means PID is unlikely)

 

 

Management

BASHH recommends a low threshold for empirical PID treatment due to:

• Lack of definitive diagnostic criteria, and
• Delaying treatment is likely to increase risk of long-term complications

Patient should be advised to attend local specialist sexual health service if hospital admission not needed.

Urgent Hospital Admission Criteria

• Clincially severe disease
• Pregnant women
• Tubo-ovarian abscess suspected
• Pelvic peritonitis suspected
• Surgical emergency cannot be excluded
• No response to oral therapy

 

General Adivce / Conservative Management

• Paracetamol and/or ibuprofen
• Avoid unprotected sexual intercourse until patient and partner(s) completed treatment and follow up

 

Women with Intrauterine Device in situ

Removal of IUD is indicated if:

• Severe symptoms at presentation
• NOT clinically improving after antibitoics

IUD can remain in situ if mild-to-moderate symptoms + clinically improving within 48-72 hours of starting antibiotics

Antibiotic Therapy

Outpatient Management

1st line → triple therapy (covers chlamydial AND gonococcal infection):

• IM ceftriaxone 1g single dose +
• Oral doxycycline 100mg BD for 14 days +
• Oral metronidazole 400mg BD for 14 days

If Mycoplasma genitalium +ve:

• Oral moxifloxacin 400mg OD for 14 days

2nd line regimen:

• IM ceftriaxone 1g single dose +
• Oral azithromycin 1g per week for 14 days

Inpatient Management

Principle:

• IV antibiotics until 24 hours after clinical improvement
• Then, switch to oral antibitoics

Regimen (either):

• IV ceftriaxone + IV doxycycline followed by oral doxycycline 100mg BD + oral metronidazole 400mg BD for 14 days
• IV clindamycin + IV gentamicin followed by oral clindamycin / doxycycline + metronidazole for 14 days

 

Follow Up

• Review within 72 hours after starting antibiotics
• Consider further review 2-4 weeks after completion of antibiotics
• Advice on future use of barrier method of contraception

Test of cure indicated if:

• +ve initial test for gonorrhoea / chlamydia / Mycoplasma genitalium
• Persistent symptoms after completing antibiotics
• Initial test results showing unknown antibiotic sensitivity or resistance (for gonorrhoea / Mycoplasma genitalium)
• Persistent / recurrent infection
• Poor compliance with antibiotic / treatment not toelrated

Management of Sexual Partners

Contact tracing + STI screening and treatment for:

• Current partners
• Recent (<6 months) partners

Whilst waiting for results, offer male partners doxycline 100mg BD for 1 week

References

Original Guideline